American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery

Anesth Analg. 2018 Jun;126(6):1896-1907.

What is already known:

A delayed return to normal GI function or the development of ileus will likely prolong hospital length of stay and several elements of ERAS are aimed towards the avoidance of GI complications. A number of definitions of ileus exist with considerable variation in their diagnostic criteria.

What this paper adds:

This paper is written by the Perioperative Quality Initiative (POQI) 2 workgroup, an international collaborative of experts in anaesthesia, surgery, nutrition and nursing. In order to better define ileus and aid in ascertaining its true incidence the group propose a rational definition of ileus or Post-Operative Gastrointestinal Dysfunction (POGD). The group propose a scoring system (I-FEED) comprising five elements helping to diagnose POGD. They go on to recommend a number of strategies aimed at reducing the incidence of POGD, several of which are found in ERAS protocols such as multimodal analgesia (with opioid avoidance) and avoidance of NG tubes. Other elements such as the use of chewing gum, coffee and alvimopan are reviewed and evidence-graded. The paper also includes evidence-based treatment strategies for patients developing POGD.

Dr Ben Morrison


Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals

Aarts MA, Rotstein OD, Pearsall EA, Victor JC, Okrainec A, McKenzie M, McCluskey SA, Conn LG, McLeod RS; iERAS group. Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals. Ann Surg. 2018 Jun;267(6):992-997.

[And accompanying editorial: Ann Surg. 2018 Jun;267(6):998-999. ERAS Implementation-Time To Move Forward. Kehlet H.]

What is already known:

A great deal of work has already been done demonstrating how improved compliance with ERAS elements can improve both short-term and long-term outcomes. This is often in a ‘dose-dependent’ fashion with increasing compliance of all elements [e.g. Gustafsson – Arch Surg 2011, Pecorelli – Surg Endos 2016, ERAS Compliance Group – Annals of Surg 2015].

What this paper adds:

This group was made up of clinicians from 15 academic hospitals in Ontario, and setup their own version of an ERAS pathway. The original project demonstrated a small 1 day improvement in length of stay with no change in readmissions. This paper aimed to determine which components of their ERAS programme had the greatest effect on recovery in colorectal surgery. This is a large study of almost 3000 patients conducted over a two-and-a-half-year period. Their self-designed programme only used 12 elements and were divided into pre, intra and post-operative pathways, with each having 4 elements. And therefore missed out on intra-operative elements such as temperature control, antibiotics etc, but also important pre-operative ones such as pre-optimisation inc prehabilitation. Patients were deemed compliant if they achieved at least 75% compliance (3 out of 4 of the elements in each pathway).
Only 20.1% of all patients were compliant with all 3 pathways. Whilst 74.7% were compliant with the pre-operative elements only 40.3% were compliant with the post-operative elements. There were some excellent gains from baseline for example rates of preoperative counselling doubled from 41.4% to 82.2% and use of CHO went from 0% to 82%, after introduction of the programme. However, some elements were still poorly adhered to, e.g. use of goal-directed fluid therapy at only 26.7%. The authors suggest this is purely down to the fact that there was no additional funding available to the sites. But other more simple interventions were also not well adhered to, e.g. use of chewing gum post-operatively was only at 52.5%.
Two potentially modifiable factors were found to significantly impact patient outcomes: laparoscopic surgery and preoperative haemoglobin levels. (A number of RCTs are in progress looking at how preoperative intravenous iron therapy can influence outcomes.) Overall higher compliance improved outcomes in both the laparoscopic and open group but the impact was significantly higher in the open group.
The authors should be congratulated on size of the study and the multi-centred nature and the fact that it was prospective. But there were a number of limitations including only recording data from patients who consented, which could be a biased towards those patients who were naturally more motivated to follow the programme. The other issue is that as an observational study causation cannot be proved but only inferred. What are the real reasons for failure in following the post-operative elements? Are there proper medical / surgical reasons or simply organisational or logistical reasons? This is where our focus needs to be in the future and how to improve the compliance of all elements.

Chris Jones, Guildford.


Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery.

Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Körner H, Erichsen C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal
surgery. Int J Surg. 2016 Dec;36(Pt A):121-126. doi: 10.1016/j.ijsu.2016.10.031. Epub 2016 Oct 22.

What is already known:

In most colorectal ERAS RCTs, patients undergoing stoma formation are often excluded. This small single-centre study looked specifically at patients undergoing colorectal surgery with stoma formation.

What this paper adds:

Whilst the authors did not define the specifics of their ERAS programme they did detail how their stoma nurse specialists focused on preoperative counselling and stoma education. Their programme demonstrated a 3 day reduction in hospital length of stay; showing that with proper preparation, undergoing stoma formation does not necessarily need to be a barrier against following a successful ERAS programme.

Chris Jones, Guildford.


Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis

Katie E Rollins, Hannah Javanmard-Emamghissi, Dileep N Lobo.Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis. World J Gastroenterol 2018 January 28; 24(4): 519-536

What is already known:

Mechanical bowel preparation (MBP) has long been part of surgical dogma; the rationale behind its use is that it reduces faecal bulk and, therefore bacterial colonisation, thereby reducing the risk of postoperativecomplications such as anastomotic leakage and wound infection, but slowly its routine use has been questioned. It has numerous physiological adverse effects secondary to the dehydration caused, it is distressing for the patient and is associated with prolonging ileus after surgery. There is also concern that it liquefies faeces and so may increase risk of spillage and therefore infection postoperatively. It remains somewhat controversial with advocates on both sides. In fact, it was even the subject of a Pro / Con debate at last year’s ERAS congress in Lyon.

What this paper adds:

This is an excellent and comprehensive meta-analysis by Professor Lobo’s group in Nottingham [NB Prof Lobo is the ERAS Society Scientific Chair]. It follows nicely on from the Cochrane review [2011], but with a further 5 RCT’s and includes over 21,500 patients versus almost 6000 in the Cochrane review. It demonstrates that at present there is no evidence that bowel preparation makes a difference to clinical outcomes in either colonic or rectal surgery, in terms of anastomotic leak rates, surgical site infection, intra-abdominal collection, mortality, reoperation or hospital length of stay. Given its potential adverse effects and patient dissatisfaction rates, it should not be administered routinely to patients undergoing elective colorectal surgery.

Chris Jones, Guildford.


The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway.

Chand M, De’Ath HD, Rasheed S, Mehta C, Bromilow J, Qureshi T. Int J Surg. 2016 Jan;25:59-63.

What is already known:

The wide-ranging benefits, including reduced hospital length of stay (LoS), of both laparoscopic surgery and ERAS have been well established. Perioperative complications are known to increase hospital LoS and mortality.

What this paper adds:

This study included a broad range of surgical procedures performed by a single surgeon using a standardised operative and anaesthetic technique. Details of patient inclusion/exclusion or compliance to ERAS guidelines are not given but it is inferred that all patients, having been recruited consecutively during the trial period, were fully followed-up with no exclusions and that there was no deviation from ERAS guidelines. The study protocol mentions the use of diclofenac, apparently as standard, for all procedures including those involving anastomosis creation (around 80% of procedures) with a 1% anastomotic leak rate. Ten patients were noted to have had a post-operative complication prior to initial discharge of which nine were classed as minor (Clavien-Dindo classification I or II) and these patients were all discharged on day two or three. The statistical analysis, however, showed an adjusted odds ratio of 16.26 for patients suffering a complication being more likely to experience a delayed discharge from hospital. It was also suggested that the study was likely underpowered to look into the effect of complications upon hospital LoS. 27 patients (9%) required readmission, the reasons for which are not detailed. Increased BMI and duration of operation were also suggested as predictors for delayed discharge but these had adjusted odds ratios of 1.06 and 0.99 respectively and of limited clinical significance.

Ben Morrison, Guildford.


Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study.

Pisarska M, Pędziwiatr M, Małczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, Kulawik J, Budzyński A. Int J Surg. 2016 Dec;36(Pt A):377-382.

What is already known:

Higher compliance with all the ERAS elements have been shown to improve outcomes, including longer term oncological outcomes. Most single centre studies look at their population as one group, and compares to another control group, but this Polish study aimed to assess short term outcomes based purely on compliance. They split the patients into three groups – high compliance (>90%), medium (70-90%)and low compliance <70%.

What this paper adds:

This study adds further weight to the argument that increased compliance improves short term outcomes. But interestingly not just between low and high compliance but also between medium and high compliance.

Chris Jones, Guildford.


A Meta-Analysis: Postoperative Pain Management in Colorectal Surgical Patients and the Effects on Length of Stay in an Enhanced Recovery After Surgery (ERAS) Setting.

Chemali ME1, Eslick GD. Clin J Pain. 2017 Jan;33(1):87-92.

What is already known:

Well managed pain relief aims to minimise side-effects and enable the main goals of ERAS to be achieved, including early mobilisation and early nutrition.

What this paper adds:

Optimal analgesia is an essential part of a successful ERAS programme, so the authors should be commended for conducting this important review. They included 21 separate RCT’s of several different types of analgesia comparisons, eg Lidocaine vs epidural, epidural vs PCA etc. This meta-analysis included colorectal RCT’s with pain as a major part of the study and length of stay as the main outcome. Overall they found no difference in their main outcome which was length of stay. However there are a number of flaws in this review. The studies they used were a mix of open and laparoscopic surgery, and not clear if all studies used a comprehensive ERAS programme as part of the standard care, in which case its difficult to draw accurate conclusions.

Chris Jones, Guildford.


Introducing an ERAS programme across a provincial healthcare system.

Nelson G, Kiyang LN, Crumley ET, Chuck A, Nguyen T, Faris P, Wasylak T, Basualdo-Hammond C, McKay S, Ljungqvist O, Gramlich LM. Implementation of Enhanced Recovery After Surgery (ERAS) Across a ProvincialHealthcare System: The ERAS Alberta Colorectal Surgery Experience. World J Surg. 2016 May;40(5):1092-103.

What is already known:

Most ERAS studies have been single centre and this is one of the first to describe how ERAS for colorectal surgery was implemented into a wider healthcare system in Alberta, Canada.

What this paper adds:

This study reports detailed results from six of Alberta’s 59 hospitals (but perform >70% of all colorectal surgery). After the ERAS programme was introduced compliance improved from 39% to 60%. They demonstrated an overall decrease in length of stay (6 to 5 days), readmissions, complications and some impressive cost savings (between $2806 and $5898 USD).

Chris Jones, Guildford.